I'm nestling into the soil, observing it all
A peregrine floats above the clouds
I don't know if I'll ever espy the root of it all
Still I press my face into the ground
I'm waitin' for the hammer to fall
- King Buffalo - Loam
Mildew, Moisture, Moulding, Damp
Most people wait until they have mouth pain before they see the dentist. Having pain in your mouth means that something is wrong, and so the dentist may fix it. They may prescribe a cleaning regimen, a filling, and extraction, or God forbid, a referral. The dentist will fix a problem that has arisen. The problem with this is that the dentist had to fix a problem that was already there. The dentist had to go into someone's mouth and do the work of repairing the weardown of teeth, gums, and surfaces that had gone too long without repair and attention. The longer the length of time without review, the greater the likelihood of problems happening, and the greater the need for more invasive intervention. Let me use another example. My bathroom is tiled, the fan is poorly placed, and there's not much ventilation. This means that moisture and dampness can collect on surfaces after every shower. If I leave it long enough, things become mildewy. If I leave it for too long, things become mouldy, and that's definitely a problem. So, instead of waiting for the mould to form, I make sure to go in and give everything a thorough clean once a week to make sure things don't get too gross. Unlike cleaning a bathroom, you probably don't need to see your dentist once a week unless you're sweet on them, but regular appointments and reviews have been proven to effectively control the risks of poor dental health, as well as decreasing the need for operative interventions.
The human body accumulates strain in the same way as teeth and bathroom surfaces accumulate stains - through use, through time, and often through inattention on the part of the occupant. Our bodies are just kind of there, they work the way we need them to and so we don't pay attention to them. Every now and then we might feel a little sore and that's not too big of a deal because maybe we sat for too long or slept a little awkwardly. This is excusable over days, weeks, months, and maybe even years. Then something inevitably happens and then it becomes the work of the physiotherapist and the patient to address not only that discomfort but to address and control the factors leading to that pain. Is it postural? Is it due to weakness? Is it due to poor technique when exercising? Is it due to doing too much or too little? These are all questions that need to be asked so that a history can be established that leads backward from the present problem into the distant past and illuminates the things that lead to the issues we're feeling now.
Most of the work done in a physiotherapy practice is in response to a problem or an event. It's rare for people to present to in advance or in absence of having any issues. Typically, the problem is discomfort of some degree of acuity or chronicity, which is either so great as to be a barrier to living or which has been going on for so long as to be almost part of the furniture but still not normal. This is reactive - a problem has to exist for us to deal with that problem, and the plan of rehabilitation focuses on addressing that problem and helping people get back to their regular function and their regular lives. This is also what most of health does as well; dealing with problems as and when they arise. This makes sense - most people live in a level of comfort that minimises the risk of pain or other problems. The issue is that dealing with problems after they arise can be costly, time consuming, and demoralising. There is, however, another solution. Just like weekly cleaning, it's entirely possible to act proactively and minimise the risk of issues happening by simple independent action.
The Problem with Proactivity
Examples of proactive health initiatives are things like pro-exercise campaigns, anti-smoking advertisements, and those extremely graphic commercials from transport insurance firms. Those programs and content are designed to address and control the risk of adverse events in the community. They can be divided into two broad groups - those that try to minimise unhealthy and negative outcomes and those that try to improve adherence to health-supporting outcomes. They emphasise the negative longterm consequences of activities like smoking and excess alcohol consumption while emphasising the positive results of activities like regular gym attendance, wearing sunscreen when you go out, and using seatbelts. Those are typically things we find in the community and we might see them incidentally without paying them much mind.
In the clinic, the same principles apply - we want to minimise negative habits and emphasise adherence to positive habits. The problem with this is that minimising and emphasising are both processes of change that might not be explicitly linked to the issue at hand. It’s pretty easy to draw a link between lower back pain and poor lifting posture. It’s harder to draw a link between lower back pain and accumulated ergonomic fatigue, muscular deconditioning, standing and walking posture, or anything to do with pelvic tilt. The problem with building proactive attitudes toward health is that proactivity is something that needs to be encouraged in the mind of the patient as a matter of engaging with the treatment. A proactive patient isn’t someone who does the exercises that they’re prescribed - that’s an adherent patient. Adherence isn’t proactivity, it’s the minimum level of participation required for change so long as that process of change is directed by a clinician. A patient who independently seeks out an exercise program, or who diarises their pain without being prompted is a proactive patient.
That’s not to say that the problem is with the patient. The problem with proactivity is that it’s a step that needs to be taken by the individual of their own volition. People will stick with exercises, management, progression and plans that solve their problems, and those problems are usually pain, stiffness, guarding and discomfort. It’s difficult to encourage people to do more on their own time if there’s no immediate problem, and it can be difficult to use the problem at hand as a jumping off point to start wider discussions about health and function in the world. The massage, stretching, exercises and work done in clinic have a clear relationship to the problem, while stuff done outside of the clinic and independently might not, because there’s no immediate buy-in. The solution to this is to have people come back regularly, which is great for the clinician and the clinic but maybe not as sustainable for the patient’s wallet and time.
The problem with proactivity and change is that it’s a challenge that’s soaked up billions of dollars in research funding, attention, time, and the lives of people across fields like healthcare, psychology, marketing and change management. Proactive change isn’t just a process of change, it’s a process of change that doesn’t have the benefit of the clear buy-in that drives adherence at the start. Pain from an injury drives attendance, and success in attendances drives adherence, but it’s harder to convince people of the benefit of doing something for which there’s no immediate problem, no immediate payoff, and sometimes no longterm payoff. You don’t resole your shoes until there’s a problem, and most people don’t see the physio until something goes wrong. Most people are reactive, but that’s not a problem either.
Being reactive is not a bad thing. Sometimes the only thing to be is to be reactive, because despite our best intentions, things can still go wrong. The slings and arrows of outrageous fortune can still inflict a thousand insults on us despite doing all the right things. Anyone who’s had their check engine light come on in the middle of a drive to the airport can attest to this, just like anyone who’s bent over to tie their shoes and had their back or hips seize up. Reactivity is a part of health because firstly, you can’t effectively eliminate or control all the risks to which you’re exposed as a matter of living, and secondly because sometimes things just happen.
Reactive healthcare is the kind of healthcare with which most people engage when they have a problem. The stereotypical presentation in physiotherapy could be an older person who pulled their back lifting their newborn child out of a pram, a weekend warrior who went a bit too hard on the box jumps, or a desk worker with neck pain after sitting through yet another meeting that could have been an email, honestly. These are problems that need to be solved. The trick is that in solving the problem, the clinician can do three things: actively solve the problem, improve a person’s ability to control that risk by understanding their own body, and build an awareness in their own mind about the necessity of continued and escalated action and learning outside of the clinic. The buy-in is already there - attendance at the clinic is driven by the presence of pain or some other problem, and if that pain or problem is managed satisfactorily that can be used to drive adherence to exercises and return consultations. All of this arose from a reactive presentation to a problem that arose either randomly, as the result of a risk that either wasn’t addressed or was ineffectively controlled, or which had happened before.
Reactive change is still change, and change is still a transformational activity. The problem with reactivity is when the presentation at clinic isn’t used to spur some kind of action in the patient. On the therapist’s side, the value of this idea can be interrogated by asking questions like, does this happen often, when was the last time this happened, have you tried anything else and so on. On the patient side of things, exposure to simple, sustainable, and successful methods of management means they’re more likely to come back after their problem has been solved or minimised and after their initial goals have been achieved, and that means more time to drive change on the therapist’s part so long as it's sustainable for the patient, and so long as there's a clear and continual benefit to attendance. The goal is to use that initial upset to provide clarity and empowerment, in the same way that treating an episode of back pain gives the therapist the opportunity to teach people about posture, to become aware of working spaces and practices, to build an awareness of their own habits and to an extent, to self-correct when they experience deviations from the norm.
A Transformation of State
Regardless of whether someone addresses their health proactively or reactively, if they seek out their own resources or receive education from trainers or health professionals, if they make up their own exercise routines or attend classes, it doesn’t make anyone more or less vulnerable. Everyone in the world is exposed to the vicissitudes of fate and circumstance because the world in which we live proceeds on so many individual arcs of development as to make it indifferent to our presence in it. We have as much awareness of the world around us as it does of our presence in it, and this is the same attitude that we extend to our bodies. Our bodies, the way in which we move through life, and how we do the things that we do are a series of assumptions on which we rely, day after day. We can control the risk of something going wrong by proactive preparation or reactive action, but even that might not fully remove the chance that something may go wrong.
Both proactive and reactive action are still action and activity undertaken to address an end. They’re both transformative processes that demand active engagement, reflection, adherence and exploration of our own capabilities, but also of our place in the world. Building an awareness of health is also about building an awareness of how factors outside of our bodies affect health and give rise to outcomes that affect us. Building an awareness of health is about understanding that the way we feel, live, and spend our time is the result of influences, available options and choices that have very little to do with us as individuals and more to do with the seemingly inscrutable mores by which the world operates around us, indifferent to us and despite us.
By moving beyond mere treatment of an injury and considering how our conception of health, what are healthy outcomes, and what actions support those outcomes are informed by the an understanding of the interaction between ourselves and the changing environment which itself evolves as we learn more about ourselves and how the world in which we live works, we can make informed decisions that don’t just support our health and wellbeing but which run to our ability to understand how the world influences and directs us, as well as understanding what it means to be healthy and well.
And that’s the most proactive thing you can do.